Preface to the Comprehensive Musculoskeletal Management (CMM) Guidelines
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Applies to Cigna-administered health benefit plans and describes the use and interpretation of the Comprehensive Musculoskeletal Management (CMM) Guidelines for musculoskeletal procedures and services, including documentation and prior authorization expectations for providers.
No material clinical or coverage changes in this revision.
Coverage Criteria
General medical necessity and documentation criteria
Covered when documentation and plan terms support medical necessity and guideline-listed indications.
Absent required documentation or when the indication is out-of-scope for the guidelines, requests may be redirected to the health plan or denied.
Coding-based Coverage Criteria
Coverage determinations follow coding relationships:
If the associated primary procedure is considered not medically necessary, the add-on code is considered not medically necessary.
Component procedure codes may be requested separately only when the component was performed independently and distinctly during a separate encounter; in that case the component code will be reviewed on its own merit.
Procedure code requests for clinical indications that are not listed within the Comprehensive Musculoskeletal Management (CMM) Guidelines may be re-directed to the health plan. The CMM Guidelines apply only to the indications explicitly included in the guideline content; when a CPT or HCPCS code is being used to represent an out-of-scope clinical indication, the request should be managed under the member's benefit plan by the health plan.
Coding-based coverage determinations consider mutually exclusive code pairs, unbundling, and other improper coding relationships. HCPCS/CPT codes are considered mutually exclusive when, based on their descriptors, the planned procedures cannot reasonably be performed at the same time on the same individual (for example, two different surgical techniques at the same anatomic site). When codes are mutually exclusive for the same date of service, the code that does not most accurately reflect the procedure as typically performed is considered not medically necessary.
Codes are considered improperly coded when the medical information supports a different code or code combination that more accurately represents the procedure, when the requested code is obsolete, when a requested code is explicitly limited to one unit but has been requested for multiple units, or when a requested code lacks additional codes required to represent the planned service.
When a single, more comprehensive code exists that more accurately represents the procedure or service performed, component procedure codes are considered unbundled and are not medically necessary if requested in addition to that comprehensive code. Component codes may only be requested separately when the component was performed as an independent and distinct procedure during a separate encounter and will then be reviewed on its own merit.
The preface clarifies that coverage policies are intended to guide interpretation of benefit plans and are not treatment recommendations. Coverage policies are used to inform medical necessity and coverage determinations and do not themselves serve as clinical treatment guidelines; plan documents or applicable laws may supersede the policy.
HCPCS/CPT codes are considered not medically necessary when they improperly reflect the planned procedure or service. Examples include inaccurate code selection where a different code or combination would better represent the procedure, requests that exceed the explicitly permitted number of units for a code, obsolete codes that should be replaced by more accurate codes, or when the requested code is integral to another procedure and therefore not separately reportable.
Add-on codes must be associated with an allowed primary procedure and cannot be reported alone. An add-on code is considered not medically necessary when the associated primary procedure is not authorized or when an add-on code is requested without a primary code. Similarly, component codes that are unbundled when a single, more comprehensive code exists are considered not medically necessary unless the component was performed independently during a separate encounter.
Coding
| CPT | Current Procedural Terminology (CPT) codes referenced; guidelines apply only to indications listed within the guidelines; CPT/HCPCS codes used for multiple indications may be redirected to the health plan for out-of-scope indications. |
| HCPCS | HCPCS codes referenced similarly to CPT; see above. |
| Category III CPT | Temporary codes for emerging technologies/procedures; use instead of unlisted when accurate. |
| Unlisted CPT/HCPCS | Unlisted codes guidance is handled in a separate Management of Unlisted Codes document. |
| No codes listed |
Provider Actions and Documentation Requirements
Prior authorization: submit full medical records; guidelines apply only to listed indications
Submit medical records documenting the individual’s current clinical status with any prior authorization request; the CMM Guidelines apply only to the indications listed within the guidelines and requests for indications not listed may be redirected to the health plan.
- Include recent virtual or in-person consultation and a complete evaluation prior to any procedure (detailed history, relevant physical exam findings, and prior treatment response).
- Provide diagnostic testing results as outlined in the specific guidelines, with advanced imaging interpreted by an independent radiologist and reconciliation of clinically significant interpretation discrepancies.
- If the requested indication is outside the CMM Guidelines, submit records explaining why an exception is being requested; absent this, medical necessity cannot be established.
Use the most accurate CPT/HCPCS code(s) for UM requests
Request the CPT/HCPCS code(s) that most accurately reflect the planned procedure or service as typically performed for utilization management review; additional claims rules may also apply.
- Codes should represent the planned procedure(s) as typically performed, not contingent procedures.
- If medical information supports a different code or code combination that more accurately represents the procedure, use that code(s).
Add-on codes require an allowed primary procedure authorization
Add-on codes will only be authorized consistent with the decision on the associated primary procedure code; an add-on requested without an allowed primary or when the primary is not authorized will be considered not medically necessary.
- Add-on codes must be associated with an allowed primary procedure per AMA CPT instructions and cannot be reported or authorized alone.
- If the primary procedure is not medically necessary, any associated add-on code is also considered not medically necessary.
Document prior procedure effect or nonperformance for sequential/similar requests
For sequential or similar/duplicate requests, provide documentation of the effect of the previously authorized procedure(s) or, if a prior authorization was obtained but the procedure not performed, documentation of nonperformance.
- Include outcomes or clinical status after the prior authorized procedure when requesting additional, sequential interventions.
- If a prior authorization was not acted upon, document why the prior authorized procedure was not performed.
Confirm procedure indication is within guideline scope before submission
When a requested procedure code represents multiple clinical indications, ensure the request aligns with an indication listed in the CMM Guidelines; procedure requests for indications not covered by the guidelines may be redirected to the health plan.
- Confirm the clinical indication for the CPT/HCPCS code matches one of the guideline-listed indications before submission.
- If the indication is out-of-scope, prepare supporting documentation for an exception or submit to the health plan per plan rules.
Request comprehensive rather than unbundled component codes when appropriate
Request the code combination that most accurately reflects the planned procedure; if a single code replaces multiple codes and more accurately represents the service, submit the single comprehensive code.
- Avoid requesting multiple component codes when a single comprehensive code exists that better represents the service.
- When appropriate, request Category III or unlisted codes per the separate guidance documents if they more accurately represent the service.
Provide complete clinical documentation prior to procedure authorization
Providers must include all required clinical documentation elements before a procedure is authorized: recent consultation, complete evaluation, detailed history and exam, prior treatment response, and relevant diagnostic testing with independent imaging interpretation.
- Complete evaluation must be performed prior to any procedure or service and include the components listed in the guidelines.
- Advanced imaging must include interpretation by an independent radiologist and reconciliation of clinically significant discrepancies in interpretations.
Document intra‑operative discoveries that change coding
If coding is changed because of intra‑operative or other discoveries that affect the procedure performed, document those findings in the medical record and submit records that support the code(s) representing the procedure as performed.
- Medical records must record any intra‑operative discovery or change that alters coding and support the revised code(s).
- The submitted documentation must show that the new code(s) accurately represent the procedure actually performed.
Request the more comprehensive code when it accurately represents the procedure
When a single, more comprehensive code more accurately represents the procedure performed, request that more comprehensive code rather than separate component codes; component codes may be requested only when performed independently and distinctly during a separate encounter.
- Unbundled/component codes are considered not medically necessary when a single comprehensive code exists that better represents the service.
- Request the component code separately only when the component was performed as an independent, distinct procedure during a separate encounter.
Verify applicable benefit plan terms and legal requirements for determinations
Coverage determinations consider the applicable benefit plan terms, any laws/regulations, relevant collateral materials (including other coverage policies), and the specific facts of the situation; conflicts defer to the customer’s benefit plan and may result in denial if the plan excludes the request.
- Always verify the member’s benefit plan document in effect on the date of service when making coverage determinations.
- In the event of conflict, the customer’s benefit plan document supersedes guideline language.
Coding errors and unsupported units/levels can trigger denials
Requests may be denied when codes do not correctly represent the planned procedure or service, including wrong code selection, unsupported number of units/levels, obsolete codes, mutually exclusive codes, add-on codes without an allowed primary, or unbundled codes when a single comprehensive code exists.
- Ensure the number of units and levels requested are supported by the medical information; codes explicitly limited to one unit cannot be requested for multiple units.
- Do not submit add-on or component codes in addition to a more comprehensive primary code.
Add-on codes submitted without an authorized primary may be denied
Requests for add-on codes submitted without an allowed primary procedure code, or when the associated primary procedure is considered not medically necessary, will be considered not medically necessary and may be denied.
- Do not submit add-on codes as standalone requests; include and obtain authorization for the associated primary procedure code.
- If the primary code is denied, remove add-on codes from the request as they will also be considered not medically necessary.
Document medical necessity for additional units/levels
When requesting additional units or levels, document why more than one unit or multiple levels are medically necessary; unsupported units/levels will be considered not medically necessary.
- Provide clear supporting clinical information for each additional unit or level requested.
- Codes explicitly limited to one unit should not be requested for multiple units.
Background
The CMM Guidelines are presented as evidence-based guidance to evaluate medically necessary musculoskeletal procedures and services. They are intended to inform coverage decision-making for Cigna-administered benefit plans but do not replace the terms of a customer's benefit plan or applicable laws; in the event of conflict, the benefit plan document governs.
Definitions
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